What screening tests should be performed in a person with a tattoo, particularly if obtained in a non-sterile environment or with a history of high-risk behaviors?

Screening for Persons with Tattoos

Routine screening for hepatitis C virus (HCV) infection should be offered to all persons with tattoos, particularly those obtained in non-professional settings, while screening for hepatitis B virus (HBV) and HIV is recommended based on additional risk factors rather than tattoo presence alone. 1

Primary Screening Recommendation: Hepatitis C

• All persons with tattoos should be offered HCV screening using enzyme immunoassays (EIA) to detect anti-HCV antibodies, as tattooing represents a recognized percutaneous exposure risk for bloodborne pathogen transmission. 1

• The risk is particularly elevated for individuals with non-professionally applied tattoos or multiple tattoos, where the association with HCV infection is stronger than with single, professionally-applied tattoos. 2, 3

• Positive anti-HCV results require confirmatory testing with either recombinant immunoblot assay (RIBA) or HCV RNA testing to distinguish active infection from resolved infection. 1

Risk-Stratified Approach to Additional Screening

High-Priority Screening (Strong Indication)

Persons with tattoos AND any of the following should receive comprehensive bloodborne pathogen screening:

• Tattoos obtained before 1992 or in unlicensed/non-professional settings (including traditional practice markings, scarification, or home-based tattooing) warrant screening for HCV, HBV, and consideration of HIV testing. 1

• Recent tattoos (within 6 months) obtained in settings with questionable infection control practices should prompt HCV screening, as the window period for antibody detection is 4-6 months. 1

• Any history of injection drug use (even once, even remote) mandates screening for HCV, HBV, and HIV regardless of tattoo status. 1

Hepatitis B Screening Considerations

• HBV screening (HBsAg and anti-HBc) is recommended for tattooed persons who also have: HIV infection, are on hemodialysis, have hemophilia, or are healthcare workers with occupational exposure. 1

• Persons found to be HBsAg-negative should complete hepatitis B vaccination series if not previously vaccinated. 1

HIV Screening Considerations

• HIV screening is not routinely indicated based solely on tattoo presence, as the evidence for HIV transmission through tattooing remains limited despite theoretical risk. 1, 4

• HIV testing should be offered when tattoos are combined with high-risk sexual behaviors, injection drug use, or other established HIV risk factors. 1, 5

Screening Timeline and Follow-Up

• For recent tattoo exposure (within 6 months): Baseline HCV antibody testing should be performed, with repeat testing at 4-6 months if initial testing is negative, as this represents the window period for HCV seroconversion. 1

• For persons with remote tattoo history: Single-time HCV screening is appropriate unless other ongoing risk factors exist. 1

• If HCV RNA testing is performed and positive, immediate referral to a specialist for treatment evaluation is indicated, as current direct-acting antiviral therapies offer cure rates exceeding 95%. 1

Important Clinical Caveats

When Standard Screening May Be Insufficient

• Licensed, professional tattoo parlors substantially reduce but do not eliminate transmission risk for bloodborne pathogens, particularly HCV. 1, 6

• The CDC guidance notes that routine testing is not necessary for tattoos from licensed establishments, but this represents a population-level recommendation; individual clinical judgment should prevail when other risk factors coexist. 1

Geographic and Cultural Considerations

• In regions with high HCV prevalence or where traditional scarification/tattooing practices are common, more aggressive screening approaches may be warranted regardless of professional versus non-professional application. 1

• Traditional practice markings, tribal scarring, and ritual circumcision with reused instruments carry similar or higher transmission risks compared to decorative tattoos. 1

Practical Implementation

• Sexual partners of HCV-infected persons should be tested even though sexual transmission efficiency is low, as negative results provide reassurance. 1

• Persons identified as HCV-positive should receive hepatitis A vaccination due to increased risk of fulminant hepatitis if co-infected. 1

• Counseling about preventing secondary transmission should accompany any positive test result, including avoiding sharing of razors, toothbrushes, and covering bleeding wounds. 1